Session Three (GAD)

Question 1

Distinguish GAD from regular fear and anxiety?

Answer 1

Excessive or unrealistic anxiety about two or more aspects of life (work, social relationships, financial matters, etc.), often accompanied by symptoms such as palpitations, shortness of breath, or dizziness.

Fear is a physiological reaction a REAL AND CURRENT stimulus (e.g. nearly getting hit but a bus). Anxiety is the physiological reaction you get on that road the next day (not current or not real). GAD is when those feelings apply to multiple stimuli and interfere with daily living.

Question 2

What are the DSM-5 criteria for diagnosing GAD?

Answer 2

• Excessive anxiety/worry more days than not over a 6 month period.
• Anxiety has to be towards a variety of stimuli (GAD vs specific anxiety disorders)
• Anxiety has to be difficult to control.
• Has to be associated with 3+ of the following symptoms; restlessness, easily fatigued, difficulty concentrating, irritability, tension, sleep disturbance.
• Clinically significant distress or impairment (N.B: Ps can still have a successful work/home/social life but still be impaired by their GAD).

Question 3

What is the onset of GAD like?

Answer 3

• Insidious, normally developed by the late teens/early 20s.
• Can develop in younger individuals, often seen as a personality trait.
• Occasionally develops in adulthood following an adverse life event.

Question 4

Why is it easier to cure adult onset GAD?

Answer 4

The cognitive processes that keep a person with GAD anxious aren’t as set in stone as they would be if the person had developed it in childhood.

Question 5

Comment on the prevalence and co-morbidity of GAD?

Answer 5

• Prevalence = 4-7%
• 2:1 Female to male ratio
• 60-90% have a co-morbidity (normally social phobia, panic disorder, depression, personality disorder)

Question 6

Define the concept of “Worry” and explain how it relates to GAD?

Answer 6

Worry = A chain of thoughts and images, negatively affect laden and relatively uncontrollable.

Worry is more common in those with anxiety disorders, and GAD sufferers specifically show more worry towards the future, greater variety in the things they worry about, and a greater tendency to let one worry evolve into another and another etc…

Question 7

What are task-related and threat cognitions and how do they relate to anxiety?

Answer 7

• Task-related cognitions = thought processes to do with the task we are currently doing (e.g. writing an essay).
• Threat cognitions = thoughts about an impending threat that may come up (e.g. thinking about an essay)
• The two are constantly competing for attention in the conscious mind, which one wins out is relevant to anxiety.
• People with GAD show difficulty in directing attention towards TRCs and away from ThrCs.

Question 8

How do people think differently when thinking about positive and negative futures?

Answer 8

• People tend to imagine positive futures visually, through imagery.
• However people tend to imagine negative futures verbally, through an internal dialogue.
• This is relevant as people with GAD are more likely to imagine neutral situations verbally, predisposing them to anxiety.

Question 9

How do the cognitive processes of Worry, Attention Control, Threat Cognitions and TR Cognitions inter-relate in GAD?

Answer 9

Worry acts as a magnet, drawing the Attention Control away from TRCs and towards Threat cognitions.

Question 10

What are the studies that provide evidence for the importance of Attention Control in GAD?

Answer 10

• Miyake et al (2000); Found some people have a limited capacity to intentionally ignore distracting information and shift attention from one topic to another, relevant as negative thoughts and worry need to be ignored to focus.
• Derryberry and Reed (2002); Found anxiety is associated with less available Attention Control.
• Hayes et al (2008); Found worry in high worriers takes up attentional control.

Question 11

Outline the method and findings of Hayes et al (2008)?

Answer 11

• Compared GAD patients to controls.
• Asked them to first perform an N-back task (basically recalling the letter 2 letters back in a series); measured general attentional control.
• Found that people with GAD were slower at recalling the letter, indicating reduced general attention control.
• Also asked them to perform a dual task (random key pressing while also being distracted by a worrying or positive topic).
• Found that GAD did worse in both, but they did much worse than the control when distracted by a worrying topic, indicating that people with GAD find it especially difficult to focus when they are in a state of worry.
• Overall conclusion; Worry takes up Attention Control in people with GAD.

Question 12

What do Dot Probe studies (MacLeod et al, 1986, 2002) tell us about the cognitive processes in people with GAD?

Answer 12

• Negative and Neutral words flash on the screen, then a line appears in space of one of them, participant is asked to say which direction the line is pointing in.
• People with GAD will tend to focus on the threatening word and therefore give the direction faster if it was over a threat word and slower over the other word (the reverse is true in non worriers).
• This suggests that people with GAD have an cognitive attention bias towards threatening stimuli, potentially affecting Threat Cognitions and therefore their ability to focus on TRCs.

Question 13

Describe the 2010 Hayes study into Benign Attentional Bias in high worriers?

Answer 13

• Found a group of high worriers.
• WPT format, did a breathing test, then a worry test, then another breathing test to compare.
• Asked to perform a dot probe task while also listening to two stories over headphones, one benign and one threatening.
• One group was asked to focus on the benign story (Benign Attentional Bias) and ignore the threatening words as a form of Attention Control training, while the other wasn’t, and listened to both.
• The group who actively tried to focus on the benign story showed less negative thought intrusions in a Worry Persistence Task.

Question 14

How does a Worry Persistence Task work in experiments?

Answer 14

• Patients are asked to focus on their breathing for a bit and report the number of negative thought intrusions (as a baseline).
• Next, they perform a task involving worry (e.g. dot probe with a negative story).
• Finally, they are asked to do the breathing task again, to see wether they experience an increase in negative thought intrusions (supposedly caused by the task).
• Self and Assessor reporting of NTIs are both important.

Question 15

What conclusions can be made from Hayes et al (2010)?

Answer 15

• Benign attentional bias reduces negative thought intrusion in those with high levels of worry.
• Causal role for threat attentional bias in contributing to difficulty in controlling worry (e.g. during a breathing task).
• Implications for CBT, can clearly teach people methods of reducing worry.

Question 16

What are the three things that can increase a person’s Threat Cognitions, potentially driving them ahead of Task Related Cognitions?

Answer 16

• Attention Bias towards threat (i.e. people have a tendency to focus their attention on more threatening stimuli)
• Threat Interpretation Biases (i.e. people being more likely to interpret a neutral stimulus as a threat).
• Mentation Style (verbal vs visual).

All 3 are targets in CBT for GAD.

Question 17

What have studies into the link between Interpretation Biases and Worry sought to prove, and what has been the results of these studies?

Answer 17

Does an inherent bias towards threat interpretation affect worry?

• Mogg et al, 1994, found more negative interpretations in individuals with GAD.
• Grey and Matthews, 2000, looked into modifying these cognitive biases
• Hirsch et al, 2018, found Cognitive Bias Modification for Interpretation training (CBM-I) was able to reduce worry symptoms, anxiety and positive responses to a scrambled sentences test (this suggests both that the training was able to affect their cognitions, and that these altered cognitions were able to help their symptoms).

Question 18

Outline the method and conclusions of Hirsch et al 2018?

Answer 18

Methods:

• Participants with GAD
• Case were given 10 Sessions of CBM-I vs Control group who were given 0.
• Measures used included self-reported worry, anxiety and scores on a Scrambled Sentence Test (lead sentence given that could be interpreted positively or negatively, count positive interpretations).
• Found a drop in anxiety and worry, paired with an increase in positive interpretations to the scrambled sentence test.

Conclusions:

• Benign interpretations reduce worry and anxiety in GAD, therefore threat interpretation bias must be a key mechanism in uncontrollable worry in GAD.
• This provides support for the role of CBM-I in CBT.

Question 19

What is the next step in CBM-I research, continuing on from Hirsch 2018’s findings?

Answer 19

Emphasising the importance of both:

• Positive imagery (actually creating images in your head of these positive outcomes)
• Self generation of positive interpretations (rather than being heavily hinted it).

Furthermore, the aim is to widen access to include more people.

Question 20

How is Hirsch investigating the addition of Mental Imagery and Active Self-Generation into CBM-I?

Answer 20

Methods:

• Again, patients with GAD
• CBM-I ++ vs CBM-I vs Control
• Measuring a variety of factors including RNTs (repetitive negative thinking aka worry), number of positive interpretations, depression, anxiety etc

Question 21

What are the early findings of Hirsch’s research into CBM-I++?

(N.B: you made up CBM-I++, don’t actually write that)

Answer 21

People with CBM vs control had decreased; anxiety, depression, RNT, weekly worry, negative thought intrusions.

AND those going through CBM-I with the added stuff showed:
- Greater increase in positive interpretations
- Greater reduction in thought intrusion (so not only does it increase the positive imagery it sought to directly address, has a secondary effect on NTIs as well)
- Reduced rumination
when compared to those just on CBM-I.

Question 22

In terms of Negative Imagery cognitive behaviours, what is unusual about GAD compared to social phobia or agoraphobia?

Answer 22

Most anxiety disorders (social phobia, agoraphobia, OCD, health anxiety, PTSD) are associated with an increase in negative imagery.

GAD however, is associated with a reduction in imagery, much more likely to worry in the form of sentences than images.

Question 23

Does the verbal nature of worry in GAD help to maintain it? What have studies shown about this effect?

Answer 23

It appears so.

Stokes and Hirsch (2010):
- Participants were all high worriers.
- Method; Ps were asked to have a focused breathing period, were then trained either verbal or visual imaging, were then given a worry task and asked to use their training method, and finally were given another focused breathing period.
- Findings: Pre-training levels across the groups were very similar, but post training the verbal group showed greater negative intrusions when the visual imagery group showed fewer.
Conclusions: Worry in its normal verbal form increases negative intrusions, verbal worry perpetuates uncontrollable worry, and CBT should target mentation style as well as content.

Question 24

Briefly describe the 2012 Model of Pathological Worry?

Answer 24

A model that seeks to bring all of Attention Control, Intrusive Thoughts, Habitual Thought Patters, Mentation Style, Biases into an explanation of worry.

Describes voluntary “top down” influences (e.g. attention control) and involuntary “bottom up” influences (e.g. internal biases and habitual thought patterns) as things that can create a verbal representation of threat, which then can cause streams of verbal worry, causing anxiety.
(best to google it).

Question 25

What are some of the difficulties of treating someone with GAD through CBT?

Answer 25

• Source of anxiety keeps changing, meaning traditional CBT methods may not be effective.
• People with GAD have a tendency towards perfectionism, which can make homework and CBT stressful. The best workaround for this is emphasising that the important thing is merely to try, thats where the good is done.
• A baseline of worry is normal, therefore its hard to tell when the patient is exhibiting GAD behaviour or just normal worry.

Question 26

What are some commonly used CBT techniques for GAD patients?

Answer 26

• Benign Outcome Imagery
• Worry Timetabling
• Worry History Outcome
• Present Moment Focus
• Worry Free Zone

Question 27

Describe Benign Outcome Imagery Therapy?

Answer 27

• First uses a worry history diary (where a patient notes down when they’re worried, why, how bad they think it will go, then how and it actually went) to establish that most of the time the outcomes of worry are benign.
• Then picks a worry, and gets the patient to identify the most likely benign outcome.
• Get them to create a vivid image of this for 2 minutes, “imagine you’re a director directing this scene, how would you set it up”
• Ask them to practice this as homework.
• Trains the patient to imagine positive outcomes, something they’ll start to do day to day as therapy goes on.

Question 28

Describe Worry History Outcome Therapy?

Answer 28

Similarly to Benign Outcome Imagery, works around a diary of worries, how bad the P thought it’d go and how bad it really went.

Aims to show the P that actually things in reality aren’t as bad as they think.

Question 29

Describe Present Moment Focus therapy?

Answer 29

Attention training.

Gets the patient to focus on what is happening around them and ignore negative thoughts or threats from interrupting. Allows them to get absorbed in the task at hand.

Question 30

Describe the Worry Free Zone method of therapy?

Answer 30

• Ask patient to think of a time in the day, a place or a task they can do that is totally worry free, e.g. making a cup of tea.
• Forces the patient to use present moment focus and ignore worry for a bit.
• Importantly, emphasis the need to be sympathetic to oneself when worry returns. In this way it avoids the initial harshness of the worry reaction, and allows the P to view the problem through a more compassionate eye.
• Every time they notice worry, let it go until they’re no longer in the worry free zone.
• This essentially trains the patients mental muscles, their ability to; Switch off anxiety, Visualise positively, Focus on task at hand, View themselves more kindly.

Question 31

Describe the Worry Timetabling method for GAD treatment?

Answer 31

• Train the P to, once they’ve noticed worry, disengage and present moment focus.
• Worry is only allowed during allocated time periods (15 or 30 minutes a day).
• MUST RETURN TO IT WITH A COMPASSIONATE VOICE. This is important to many forms of GAD therapy, and can be helped along by asking the P to imagine how they’d respond to a friend in their worry situation.
• Goal: To not discard worry, just to delay it. This allows the patient to focus on task at hand, exert control on their worry and actually reduces the worry when they come back to it as they’ve either forgotten it or it doesn’t seem as bad as it did at the time.

Question 32

Describe how Behavioural Experiments can help patients with GAD?

Answer 32

This is a tactic that works well for more specific anxieties within GAD. Often GAD patient care generally anxious, but also have some recurring, specific worries.

• Takes a worry (e.g. I must be a perfect hostess or people will hate me)
• Challenges it (e.g. don’t do some of the things you normally would, in this case delegate hosing jobs)
• Gets the patient to analyse the challenge (e.g. by examining how they felt during it, how others thought of it)
• Often the worry is shown to be nonsense and the patient will eventually be less prone to it.
• Very effective for a range of worries e.g. food poisoning.